Childcare Daycare Registration Form

CHILDCARE DAYCARE REGISTRATION FORM

Child Information

Child Full Legal Name:

Preferred Name/Nickname:    Date of Birth:    Sex:

Parent / Guardian Information (Primary)

Parent / Guardian Information (Secondary)

Emergency Contacts & Authorized Pickups

Emergency Contact 1 - Name:    Phone:    Relationship:

Emergency Contact 2 - Name:    Phone:    Relationship:

Enrollment & Program Information

Desired Program:    Start Date:

Monday    Tuesday    Wednesday    Thursday    Friday

Medical & Health Information

Parent / Guardian Employment History (Required)

Employer 1

Employer 2

Education

References (Professional)

Reference 1 - Name: Phone: Email:

Reference 2 - Name: Phone: Email:

Reference 3 - Name: Phone: Email:

Legal Disclosures & Authorizations

At-Will Employment Statement: I acknowledge that any employment by this childcare provider of the undersigned parent/guardian or any employee is at-will, meaning employment may be terminated by either party at any time, with or without cause or notice. This statement applies solely to employment relationships and does not alter or affect the child's enrollment rights. Please initial to acknowledge:

Initials:

Equal Opportunity Statement: This childcare program admits children and employs staff without regard to race, color, religion, national origin, sex, disability, or any other characteristic protected by law. Please initial to acknowledge receipt of this statement:

Initials:

Authorization to Seek Emergency Medical Treatment: In the event of a medical emergency and reasonable attempts to contact parent/guardian have been unsuccessful, I authorize the facility to arrange for emergency medical treatment for my child. I understand that I will be responsible for all costs incurred. Please initial to grant authorization:

Initials:

Photo/Media Release: I authorize the facility to use photographs, videos or recordings of my child for educational, promotional, or training purposes, without compensation. If you do NOT consent, check here:

Field Trip Authorization: I authorize my child to participate in program-sponsored activities and off-site walks/trips as supervised by staff. Specific trip notices will be provided in advance. If you do NOT consent to off-site trips, check here:

Background Check and Employment Verification Authorization (applies to parent/guardian who may be employed or volunteering in a direct care capacity): I authorize the facility to contact prior employers and conduct background checks where permitted by law. Consent:

Discipline and Health Policies Acknowledgment

I acknowledge that I have received, read, and understand the facility's discipline policy and health/exclusion policy, including required exclusion periods for communicable diseases and procedures for administering medication. I agree to adhere to procedures and to inform the facility of any communicable disease diagnosis. Please initial to acknowledge:

Initials:

Applicant / Parent Certification

By signing below I certify that all information provided on this registration form is true and complete to the best of my knowledge. I understand that omission or falsification of material facts may result in termination of enrollment. I authorize the facility to contact the persons and institutions listed on this form for verification and emergency purposes. I understand and agree to the published fees, payment schedule, and termination policy.

Consent to Treatment and Release: I release the childcare provider and its employees from liability for non-negligent acts and acknowledge that the provider will exercise reasonable care in the supervision and treatment of my child. This release does not cover gross negligence or willful misconduct.

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